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Masterfile

April 17, 2018

How does having a traumatic brain injury (TBI) at a young age affect children as they get older? New research has found a link between TBIs and a child’s likelihood of developing attention deficit hyperactivity disorder (ADHD).

Researchers examined hospital data on 187 children between the ages of 3 and 7, including 81 who experienced overnight hospital stays for a TBI and 106 who were hospitalized for orthopedic injuries. None of the children studied had been diagnosed with ADHD before their injuries.

The research, published in JAMA Pediatrics, found that kids who suffered a TBI were more than 3 times as likely to develop ADHD than kids with other injuries.

ADHD is the most common psychiatric disorder among children with a history of TBI, the researchers noted.

For this study, parents reported their child's ADHD symptoms, history of diagnosis, and prescribed medication back to the researchers for roughly seven years, or up until middle school age.

“This developmental period includes a great increase in the demand for executive functioning, organization, and independence,” says lead researcher Megan Narad, PhD, a psychology fellow at Cincinnati Children’s Hospital in Cincinnati. “Assessing kids during this period allowed us to learn how children who had sustained a TBI many years earlier function within the context of these new demands.”

Dr. Narad also noted two surprises from this research.

“First, those with moderate injuries, not the most severe, had 2 times the risk of developing SADHD [secondary attention deficit hyperactivity disorder] than those without TBI,” Narad says, adding that the finding suggests that injury severity isn’t the whole problem when it comes to the development of attention problems following a TBI.

In the report, Narad and her team refer to SADHD rather than ADHD to refer to ADHD symptoms that began after injury.

The other interesting finding was just how many children were developing ADHD closer to the start of their middle school years, nearly a decade after experiencing their injuries. Narad says this suggests that difficulties from TBI can develop many years after an injury.

But many children who have ADHD aren’t diagnosed until they’re older than the group in this study, says Erin Murdock, MD, a pediatric psychiatrist at Cleveland Clinic Children’s Hospital for Rehabilitation in Cleveland. She adds that, without an assessment before the injury, it’s particularly hard to prove that these kids had no signs of ADHD before their TBI, but that children and adults with a TBI are more likely to have inattention, impulsivity, and poor safety awareness. She also says that kids who have ADHD prior to a brain injury are more likely to have worsening symptoms after the injury.

To Dr. Murdock’s point, Narad says that she and her team excluded kids whose parents reported that they had significant attention problems prior to their TBI. She says there is the chance that some of these kids would have developed ADHD regardless of any kind of injury.

“That being said, if the injury had no impact on SADHD development, we would expect the proportion of patients in the study who developed it to be consistent with the general population rate of ADHD, which is about 8 to 10 percent,” she adds.

“I think it is crucial that we are aware of these symptoms and addressing if they require medical or behavioral treatment in order to help these children be successful in school, and this study helps raise that awareness,” Narad says.

Murdock, who is not affiliated with this research, says the study is important in that it highlights the need for long-term follow up in children who have suffered a TBI.

“A young child is not expected to be able to do [the same] complex problems and ideas as a teenager, thus the deficits from their brain injury may not be apparent until they are older, when they are having more difficulty in school than their peers,” she adds. “Many children who recover from their brain injury are doing well physically, and their intellectual functioning tends to be overlooked or not addressed.”

The study should be something of a wakeup call to parents and doctors alike. Narad says that on the healthcare end of things, it would be important for caregivers to discuss with parents the potential for developing ADHD down the line after a TBI. She stresses that it is also important that clinical providers be vigilant about this possible risk.

“I think it is important to continue to monitor your child’s behavior, attention, and academic functioning even years after an injury,” she says.